Prenatal Family History Worksheet Form

INSTRUCTIONS: Please complete a worksheet for each family member for whom information is available. This includes a worksheet for you and one for your mate, as well as one for each sibling, niece, nephew, parent, aunt, uncle, first cousin and grandparent on both sides of your and your mate's families.

General information:



Date of birth:

Place of birth:


Known diseases or other health problems:

Date of death:

Age at death:

Cause of death:

Child bearing history:

Number of children:

Birth defects:

Number of miscarriages:

Number of stillborn babies:

Children born with low birth weight – lower than 5. lbs:

Premature births:

Mental retardation:

Slow development:

Age of children's deaths:

Cause of children's deaths:

Add information from each family member's worksheet to the Summary Prenatal Family History Worksheet.